Special air-blowing vests keep patients warm pre-surgery. Private rooms are the norm. Staffers regularly check in with patients to anticipate their toilet and showering needs to cut down on call-light usage. Patients are given clear discharge instructions. Cleaning is no longer done at night. Patients are taught the difference between "pain-free" and "pain-controlled."

The reason for these changes at Providence Park and similar ones at other hospitals across the country is to ensure high scores on patient satisfaction surveys, the results of which will affect Medicare reimbursement rates, starting next year.

Bobbie Squires of Brighton, Mich., holds her day-old son, Fischer Squires, in her room at Providence Park Hospital in Novi. The hospital's rooms are private and have flat-screen televisions and convertible couches so relatives can stay if necessary.(Photo: Regina H. Boon, Detroit Free Press)

At issue are millions of dollars annually, all the more significant as the industry sees so many other dollars slipping away. In fiscal year 2013, for example, the pot is $964 million, according to the federal government's Centers for Medicare & Medicaid Services.

Amenities such as free lattes and valet parking are not new to hospitals. They began offering them years ago in a high-stakes fight to lure patients. However, what hospitals are doing now is, for the most part, tailored to the survey questions they know patients will be asked.

Noise is a big topic. Providence Park has reduced the number of loud carts pushed along its corridors. Instead, patients get "quiet kits" containing ear plugs and relaxation-inducing lavender lotion.

Another survey topic is staff attention.

"Bells and whistles make it a nicer environment for patents, but if you're not addressing holistic, spiritual care, they're not going to rate it well," said Dr. Linda Dubay, St. John Providence Health System's chief quality officer. "We take these things and focus it up from there in addressing the patients' needs."

The Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS (pronounced H-caps) — first instituted in 2006 as a 27-question survey for discharged patients — was initially designed to be a comparison tool people could use to choose a hospital. Under the Affordable Care Act, it morphed into a dollars-loaded query in October, the start of the 2013 fiscal year.

In January, another five questions will be added.

Hospitals are at risk of losing 1% of their payouts this year if they don't do well on the surveys. That will jump to 2% by fiscal year 2017.

They have to submit a minimum of 100 surveys. To prevent them from cherry-picking the most favorable replies, the Centers for Medicare & Medicaid Services will do quarterly random audits of data.

"In the past, hospitals and other providers were paid almost solely based on how much work they did — not on how well they did for patients," the Centers for Medicare & Medicaid Services said in an e-mail. "Since the ACA, however, we have a number of programs in place ... that reward hospitals and doctors based on the quality of care they deliver for patients."

Among the topics in the surveys are:

• Nursing and doctor care (Did they treat you with courtesy and respect and explain things to you clearly?).

• The hospital environment (Was your room clean and quiet).

• Pain (Was your pain well-controlled).

• The discharge process.

At Botsford Hospital, changes include nurses talking to patients hourly to inquire if they need to use the bathroom and to ensure all personal items such as water, the call button and the phone are within arm's reach; audio-video relaxation system in patient rooms, and detailed "Passport to Care" discharge packets.

"It's important to score that well, because that reflects we're doing the right thing for our patients," said Kim Guesman, Botsford's director of nursing services. "We're not doing it just for the money. We're doing it because it's the right thing to do."

But others in southeastern Michigan, like St. Joseph Mercy and Beaumont health systems and Sinai-Grace Hospital, said they aren't motivated by the Medicare payments to improve patient care.

"We don't frankly respond to changes in reimbursement or other national surveys and comparisons," said Tom Brisse, Beaumont's executive vice president of operations. "We've been working for decades to improve patient satisfaction."

He said that less than $3 million is at stake, a tiny portion of the hospital's $2.2 billion operation.

Rajesh Balkrishnan, a University of Michigan associate professor of pharmacy and public health who has researched patient satisfaction surveys, said this regulatory move is a positive one, citing among other reasons the importance of patient empowerment.

"The problem is America is a free-market economy," he said. "We need to give patients a way to speak on what they think about health care, what works for them, how health care professionals work for them, because those factors go into determining whether treatments are successful."